Sources of Variability in the Detection of B-Lines, Using Lung Ultrasound

Lung ultrasound (LUS) is a largely employed diagnostic tool but an operational protocol for implementation has never been proposed. The lack of standardization clearly introduces variability in LUS results. We enrolled adult patients presenting for acute dyspnea with a clinical suspect of etiology related to heart failure. We calculated agreement among four providers in assessing B-lines. We varied probes, depth, evaluation time and scanning areas and we estimated the importance of each factors on B-lines assessment. Overall agreement among raters varied from a kappa of 0.70 to 0.81. The mean number of B-lines was 5.44 (95% confidence interval, CI, 4.1-6.8). This estimate did not suffer variation by the depth used (0.03, 95% CI -0.2-0.2, more B-lines, using 19 cm versus 10 cm). The use of a convex probe and expertise in LUS reduced the number of artifacts by 1.7 (95% CI 1.5-1.9) and 1.1 in comparison with a phased array probe and naive operators. Evaluation time increased estimates by 1.2 (95% CI 1-1.5) and 2.9 (95% CI 2.7-3.9) B-lines for 4" and 7" clips (reference was 2" clips). This study suggests that the probe, the evaluation time and the level of expertise might affect the results of quantitative assessment of B-lines.